Van Rooyen, Julian

Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Julian Van Rooyen,
on 17 July 2023, following his
release from HMP The Mount
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
© Crown copyright, 2024
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. From 6 September 2021, the PPO investigates post-release deaths that occur
within 14 days of the prisoner’s release.
3. If my office is to best assist HM Prison and Probation Service (HMPPS) in ensuring
the standard of care received by those within service remit is appropriate then our
recommendations should be focused, evidenced and viable. This is especially the
case if there is evidence of systemic failure.
4. Mr Julian Van Rooyen, a Zimbabwean national, died of cocaine toxicity on 17 July
2023, following his release from HMP The Mount 12 days earlier. He also had
bronchopneumonia (a lung infection) which contributed to but did not cause his
death. He was 44 years old. I offer my condolences to his family and friends.
5. Mr Van Rooyen had a history of substance misuse and had engaged with
community substances misuse services. However, at The Mount, Mr Van Rooyen
did not engage with the substance misuse service and declined an assessment with
the Forward Trust’s substance misuse service and their Improving Access to
Psychological Therapies service.
6. On 6 July 2023, the day of his release, Mr Van Rooyen met a probation officer at
the Milton Keynes probation office. Mr Van Rooyen did not attend his next planned
appointment on 12 July. Probation staff did not send Mr Van Rooyen a letter
informing him that he had breached the terms of his licence, nor did they rearrange
a new appointment for him as they should have done.
7. At 2.00pm on 17 July, Mr Van Rooyen’s friend found him dead in his release
accommodation. Police officers found 15 to 20 wraps of what appeared to be illicit
drugs and a crack pipe.
Prisons and Probation Ombudsman 1
The Investigation Process
8. On 26 July 2023, the PPO was informed of Mr Van Rooyen’s death.
9. The PPO investigator obtained copies of relevant extracts from Mr Van Rooyen’s
prison and probation records.
10. We informed HM Coroner for Northamptonshire of the investigation. She gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
11. The Ombudsman’s family liaison officer wrote to Mr Van Rooyen’s aunt to explain
the investigation and to ask if she had any matters she wanted us to consider. Mr
Van Rooyen’s aunt asked who he had lived with in his release accommodation and
who had found him after he had died. Mr Van Rooyen’s aunt said that she was
shocked to find out from social media that Mr Van Rooyen had died.
12. We shared the initial report with HM Prison and Probation Service. There were two
factual inaccuracies, and this report has been amended accordingly.
13. We shared the initial report with Mr Van Rooyen’s aunt. She did not respond.
2 Prisons and Probation Ombudsman
Background Information
HMP The Mount
14. HMP The Mount is a Category C training and resettlement prison holding
approximately 1,000 men. Practice Plus Group provides primary healthcare and
mental health services. The Forward Trust provides psychosocial substance misuse
services.
HM Inspectorate of Prisons
15. The most recent full inspection of HMP The Mount was in March 2022. Inspectors
found that rehabilitation and resettlement planning was not sufficiently good overall.
Inspectors reported that there was an insufficient focus on and opportunities for
sentence progression. They said that there were few interventions, besides
accredited offending behaviour programmes, to help prisoners reduce their risk and
make progress. Inspectors found that the backlog of offender assessments (OASys)
had reduced and completed assessments and sentence plans were of good quality.
Prison offender manager (POM) contact with prisoners was poor in too many cases
and some POMs felt that their caseloads were too high to complete regular
meaningful one-to-one work, although inspectors saw some examples of
outstanding work.
16. In February 2023, inspectors conducted an independent review of progress at The
Mount. They found that there was insufficient focus on or support for sentence
management, and there remained few interventions to help prisoners reduce their
risk and make progress. Inspectors reported that there had been ‘no meaningful
progress’ in support for sentence progression, and prisoners were frustrated at the
lack of contact with POMs.
Probation Service
17. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
Key Events
18. On 4 October 2021, Mr Julian Van Rooyen was remanded to HMP Bullingdon for
assault and drug trafficking.
19. At his initial health screen, Mr Van Rooyen told a nurse that he spent £10 to £20 a
day on heroin and was withdrawing from opiates. Mr Van Rooyen tested positive for
cocaine and negative for heroin and opiates. The nurse referred Mr Van Rooyen to
the substance misuse service.
20. On 5 October, another nurse saw Mr Van Rooyen for a substance misuse review.
The nurse noted that Mr Van Rooyen used a £10 bag of heroin a day and used
crack cocaine two days a week, spending between £50 and £100. Mr Van Rooyen
said that his community GP prescribed him tramadol (a strong pain killer) as he had
had a motorcycle accident in 2005 and that Addiction Recovery Community, Milton
Keynes (ARC - substance misuse service) gave him buprenorphine (for heroin
withdrawal). A GP at Bullingdon reviewed Mr Van Rooyen and concluded that he
did not require methadone for opioid withdrawal. (Throughout his time in prison Mr
Van Rooyen did not receive methadone.)
21. On 17 June 2022, Mr Van Rooyen was convicted and sentenced to three years and
six months in prison.
22. Mr Van Rooyen was appointed a community offender manager (COM).
23. On 4 July, Mr Van Rooyen was transferred to HMP Bedford, and, on 11 July, he
was transferred to HMP The Mount.
24. On 20 July, Mr Van Rooyen was allocated a prison offender manager (POM).
25. At his initial health screen at The Mount, Mr Van Rooyen told a nurse that he had
anxiety and depression. He told her that he did not have a problem with alcohol or
illicit drug use. At The Mount, Mr Van Rooyen did not engage with the substance
misuse service.
26. An integrated service manager with the Forward Trust told us that after a routine
induction, Mr Van Rooyen declined an assessment with the Forward Trust’s
substance misuse service and their talking therapies programme (for prisoners
diagnosed with anxiety or depression).
27. On 4 August, the POM completed Mr Van Rooyen’s Offender Assessment System
(OASys) risk and needs report. Mr Van Rooyen told her that he started using heroin
and crack cocaine in 2016 and committed crime to fund his habit. He said that
before he committed the offence for which he was currently in prison, he drank half
a bottle of vodka but said that alcohol was not a problem for him. Mr Van Rooyen
told her that he had previously accessed substance misuse services at ARC. Mr
Van Rooyen said that he would be released homeless but intended to live with a
close friend.
28. On 18 August, the COM emailed (through the email a prisoner scheme) Mr Van
Rooyen and asked him to arrange a meeting with him to discuss his release
options.
4 Prisons and Probation Ombudsman
29. On 6 October, Mr Van Rooyen was appointed another community offender
manager.
30. On 8 November, the COM emailed Mr Van Rooyen and asked him to make contact
with him before his release. There is no record that Mr Van Rooyen responded to
the email.
31. On 12 December, a probation officer was allocated as Mr Van Rooyen’s prison
offender manager.
32. On 13 January 2023, the POM saw Mr Van Rooyen, who told him that he would be
released homeless. He emailed the COM and told him that Mr Van Rooyen would
be released homeless and asked him to consider an Approved Premises (AP) or
the Community Accommodation Service (CAS3, which provides temporary
accommodation for up to 84 nights for homeless prison leavers) in the Northampton
area (where Mr Van Rooyen said he had family). The POM told the COM that Mr
Van Rooyen’s risk meant that he could not be considered for an AP.
33. On 9 March, the COM noted that Mr Van Rooyen was of interest to the Home
Office, as he was a Zimbabwean national.
34. On 17 April, a senior probation officer met the POM to discuss Mr Van Rooyen. He
noted that Mr Van Rooyen had a friend in Northampton who would offer him
accommodation on his farm and offer him employment. The POM told him that he
would speak to Mr Van Rooyen’s friend to verify the accommodation and the offer
of employment and speak to the Northampton probation office once this had been
verified.
35. On 19 May, Mr Van Rooyen’s friend emailed the POM and told him that he had
secured an interview for Mr Van Rooyen at a bakery and that there was an
opportunity for Mr Van Rooyen to work on his farm maintaining machinery. He said
that he had offered Mr Van Rooyen a place to live on a narrow boat near to his
farm. Mr Van Rooyen’s friend later emailed the POM and told him that there would
be a delay in the arrival of the narrow boat but that he could live in a mobile home
on the site before it’s arrival.
36. On 23 June, Mr Van Rooyen’s friend gave the POM the address of the farm where
he would live and the address of the marina where the boat would be moored.
37. On 28 June, an officer from the Home Office emailed the POM and told him that Mr
Van Rooyen would be electronically tagged on his release.
38. On 5 July, Mr Van Rooyen was due to be released on licence. The Home Office
delayed his release by a day because they had not completed their paperwork. Mr
Van Rooyen’s licence conditions required him to report at 2.00pm, to the Milton
Keynes probation office. His licence conditions required him to be tested for illicit
drugs when required by his community offender manager.
39. The Home Office agreed to give Mr Van Rooyen immigration bail while they
assessed a claim for asylum that he had made. Mr Van Rooyen’s bail required him
to live on the farm identified by his friend and to report at 10.00am on 11 July, to
Weston Favell Police Station in Northamptonshire. (We do not know if Mr Van
Rooyen reported as required.) Mr Van Rooyen’s bail also required him to be subject
Prisons and Probation Ombudsman 5
to electronic monitoring and that, on 6 July, a member of staff from Electronic
Monitoring Services (EMS) would go to The Mount to fit the electronic tag.
40. On 6 July, staff from EMS saw Mr Van Rooyen at The Mount and fitted the TAG,
but due to signal issues they were not able to ‘successfully confirm installation’.
They said that they would not be able to verify that the information being relayed
from the TAG was 100% accurate.
41. That day, a nurse saw Mr Van Rooyen and noted that he had no outstanding
hospital appointments. Mr Van Rooyen did not want help to register with a GP
Practice.
Post-release
42. On 6 July, Mr Van Rooyen reported to a probation officer at the Milton Keynes
probation office. She completed the induction paperwork, which Mr Van Rooyen
signed. She gave Mr Van Rooyen an appointment slip for his next appointment for
12 July.
43. On 8 July, EMS staff visited Mr Van Rooyen’s bail address and received a
withdrawal of consent from the homeowner, which they reported as a breach to the
Home Office. A team manager at EMS said that in these situations they do not visit
the address again until they receive an update from the Home Office in the form of
a new installation request or a response to the breach that has been issued. (The
investigator asked the Home Office what action they had taken following the
breach, but they did not respond.)
44. On 10 July, Mr Van Rooyen was allocated another community offender manager.
45. On 11 July, the battery on Mr Van Rooyen’s TAG failed and no further data was
received from it.
46. On 12 July, Mr Van Rooyen did not attend his planned probation appointment. He
was not contacted or seen again by probation staff.
Circumstances of Mr Van Rooyen’s death
47. At 2.00pm on 17 July, Mr Van Rooyen’s friend, who had been unable to contact him
throughout the day, went to the mobile home where he was living and found him
dead. At 4.21pm, ambulance paramedics confirmed that Mr Van Rooyen had died.
In the mobile home, police officers found 15 to 20 wraps of what appeared to be
illicit drugs and a crack pipe.
Post-mortem report
48. A post-mortem established that Mr Van Rooyen died from cocaine toxicity. He also
had bronchopneumonia (a lung infection) which contributed to but did not cause his
death. A consultant histopathologist said that Mr Van Rooyen had used cocaine
close to the time of his death. He said that the cocaine use could lead to fatal
arrhythmia (irregular heartbeat) and seizures. The histopathologist also said that Mr
6 Prisons and Probation Ombudsman
Van Rooyen had used heroin, but the morphine levels were very low at the time of
his death.
Inquest
49. At an inquest held on 20 March 2024, the Coroner concluded that Mr Van Rooyen’s
death was accidental.
Support for staff
50. After Mr Van Rooyen died, a senior probation officer reminded staff of available
support services.
Contact with Mr Van Rooyen’s family
51. Police officers were unable to identify Mr Van Rooyen’s next of kin. Mr Van
Rooyen’s aunt found out on the social media site Facebook that he had died and
telephoned the police, who then formally told her that Mr Van Rooyen had died.
Prisons and Probation Ombudsman 7
Findings
Substance misuse services
52. Mr Van Rooyen had a history of substance misuse in the community. He had
engaged with community substance misuse services in the past but declined to
work with prison drugs services. Mr Van Rooyen might have benefitted from
engagement with prison substance misuse service, and by choosing not to do so
they were unable to offer him naloxone (medication to reverse the effects of opiate
overdose) on release or to remind him of the dangers of returning to drug use on
release due to reduced tolerance levels.
Regional Probation Director to note
Non-compliance with licence conditions
53. Mr Van Rooyen did not attend his planned probation appointment on 12 July, at the
Milton Keynes probation office.
54. A probation officer said that the POM, who was leaving the Probation Service, was
in the process of handing Mr Van Rooyen’s case to her and by this date the
handover had not happened. She said that Mr Van Rooyen’s non-attendance
should have been recorded as a breach of his licence conditions and a letter
explaining this should have been sent to him as a licence warning. This did not
happen. She said that in these circumstances they should have booked a new
appointment in five days. This did not happen, and Mr Van Rooyen was not seen by
her or staff from the Probation Service.
55. A senior probation officer said that Mr Van Rooyen’s non-attendance on 12 July
should have been recorded as an unacceptable failure of his licence conditions.
She said that this should have resulted in a warning letter being sent within two
working days, which should have given a new appointment (within five working
days). This was not done and there is no record that Mr Van Rooyen had any
further contact with the Probation Service up to his death on 17 July. The Regional
Probation Director will wish to consider the findings of this investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2024
8 Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk